Appeals Of Utilization Review Decisions

(1) Every denial of a recommended treatment shall be accompanied by a form prescribed by the Bureau that informs the employee as defined in these rules and authorized treating physician how to request an appeal with the Bureau. The employee or authorized treating physician shall have thirty (30) calendar days from receipt of the initial denial or the denial on reconsideration by an employer as defined in these rules to request an appeal with the Bureau. The form and accompanying instructions provided shall be the current form and instructions adopted by the Bureau and posted on the Bureau’s website. The Medical Director may extend the time to appeal for good cause. (2) Upon receipt of an appeal request by an employee or authorized treating physician: (a) The Bureau or its designated contractor shall conduct the utilization review appeal. The Bureau or its designated contractor may contact the authorized treating physician for the purpose of obtaining any necessary missing information. The Bureau or its designated contractor shall determine the medical necessity of the recommended treatment as soon as practicable after receipt of all necessary information. The Bureau or its designated contractor shall then transmit such determination to the authorized treating physician, employee, and employer. The determination of the Bureau or its designated contractor is final for administrative purposes, subject to the provisions of subsections (3)–(5) of this Rule. (b) If any information necessary for the determination of the appeal is not within the possession of the Bureau, then any party not providing such information when requested by the Bureau may be subject to sanctions and/or civil penalties as set forth in Rule 0800-02-06-.10, at the discretion of the Administrator. (c) The Bureau shall charge fees, as posted on its website, pursuant to Public Chapter 289 (2013) and T.C.A. § 50-6-204(j) for each utilization review appeal that it completes. The fee shall be paid by the employer within thirty (30) calendar days of the Bureau’s completion of the appeal. Failure to comply with this requirement may result in a civil penalty of not less than $50 nor greater than $5000 per violation. If there is a pattern of violations, the Administrator may consider suspension of participation in the Bureau’s utilization review program. If the fee and/or penalty remain unpaid for a further 30 days, the Administrator may impose further civil penalties or sanctions, or request that the Department of Commerce and Insurance apply penalties/sanctions in accordance with their policies. The appeal of any fee or civil penalty assessed pursuant to this section shall be made in accordance with the Uniform Administrative Procedures Act, T.C.A. §§ 4-5-101, et seq., and the most current procedural rules of Chapter 0800-02-13, as may be amended periodically in the future, which are incorporated as if set forth fully herein. (3) If the determination of the Bureau is an approval of part or all of the recommended treatment, then the Medical Director shall issue a determination that specifies the treatment(s) that is/are medically necessary. The penalty provisions of T.C.A. §§ 50-6-238 and 50-6-118 shall apply to these determinations issued pursuant to this subsection (3). (4) For dates of injury on or after July 1, 2014, if the determination of the Medical Director is to approve part or all of the recommended treatment, then within seven (7) calendar days of the receipt of the determination letter from the Medical Director, referenced in subsection (3) above, the insurance carrier is required to inform the provider that the procedure and/or treatment, including medications, has been approved and request that the procedure or treatment be scheduled. The penalties for noncompliance with this subsection are those set forth in T.C.A § 50-6-118. GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW (5) A determination of denial is effective for a period of 6 months from the date of the determination as set forth in Rule 0800-02-06-.06(7). (6) For dates of injury on or after July 1, 2014, notwithstanding the provisions of subsection (4), if any party, including an employee, employer, or a carrier, disagrees with a determination of the Medical Director’s recommended or denied treatment, then the aggrieved party shall file a Petition for Benefit Determination (PBD) with the Court Of Workers’ Compensation Claims within fifteen (15) calendar days of the receipt of the determination to request a hearing of the dispute in accordance with applicable statutory provisions. To avoid a penalty for non- compliance with the Medical Director’s order, an employer who files a Petition for Benefit Determination (PBD) shall also request a stay of enforcement from the Court of Workers’ Compensation Claims pending the outcome of the Petition for Benefit Determination (PBD). (7) For dates of injury prior to July 1, 2014, if the determination of the Medical Director is to approve part or all of the recommended treatment, and an order for medical benefits is issued by the Bureau, within fifteen (15) calendar days of the receipt of the order the insurance carrier is required to inform the provider that the procedure and/or treatment, including medications, has been approved and request that the procedure or treatment be scheduled. The penalties for noncompliance with this subsection are those set forth in T.C.A § 50-6-238 [Applicable to injuries occurring prior to July 1, 2014]. The determination of the Medical Director is final for administrative purposes. If the employer disagrees with the determination, the employer may file a Request for Mediation (RFM) with the Bureau or civil action with a court of proper jurisdiction and shall request a stay of enforcement from the Bureau penalty program pending the outcome of the Request for Mediation (RFM) or civil action in a court of proper jurisdiction. (8) Notwithstanding any other provision to the contrary, if the parties agree on a recommended treatment after the employer’s utilization review organization has denied such, then the parties may, by joint agreement, override the determination of the employer’s utilization review organization or the Bureau and approve the recommended treatment. Such approval by agreement shall terminate any appeal to the Bureau and no fee shall be required of the employer for any such appeal that has yet to be determined by the Bureau.